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Exposed to trauma w/in last 30 days Assess environments for ongoing threats. Protect from further harm. Ensure basic physical needs are met. Immediate needs include: - Survival (including first aid and stabilizing physical condition), safety, security
- Food, hydration, shelter, clothing
- Sleep
- Orientation
- Communication w/ unit, family, friends, community
- Education and normalization of rxns to trauma
If unstable, suicidal, or dangerous to self or others, or in need of urgent medical or surgical attention: Assess hx and s/sx, esp. for acute stress d/o (ASD). - ASR
◦ A transient, NL rxn to traumatic stress
◦ Can present w/ broad group of physical, mental, behavioral, and emotional s/sx—e.g., confusion; sadness; depression; fatigue; anxiety; social withdrawal; ↓concentration, memory, or both; hyperarousal; dissociation
◦ Might be temporarily debilitating
◦ S/sx onset might be simultaneous or w/in minutes of the traumatic event or might occur hours or several days later - COSR
◦ Physical, emotional, cognitive, or behavioral rxns, adverse consequences, or psychological injuries of service members who’ve been exposed to stressful or traumatic events in combat or military operations
◦ Identification based on observation of behavior and functioning and on clinical assessments; insufficient evidence to recommend a specific screening tool.
◦ Pt should receive comprehensive assessment of sx or behavioral signs; it should include details about the onset, frequency, course, severity, level of distress, work performance, functional impairment, and safety risks based on the pt’s occupational responsibilities.
◦ Assess for medical causes of acute changes in behavior—e.g., TBI, substance use, toxic exposures.
◦ Collateral info from unit leaders, coworkers, and peers should inform eval of active-duty service members.
To prevent PTSD in individuals exposed to trauma, there’s insufficient evidence to recommend for or against psychotherapy or pharmacotherapy in the immediate post-trauma period.
Persistent/worsening traumatic stress sx or at risk for PTSD Obtain clinical assessment. Assess function and duty/work responsibilities. Assess risk and protective factors. In the general assessment: - Complete comprehensive clinical assessment of presenting complaints and comorbid conditions.
- Perform safety, lethal means, and environmental assessment.
- Consider hx and presenting complaints: mental health, medical, military, marital, family, substance use, social and spiritual life, functional status.
- Identify lifetime trauma hx and duration of exposure.
- Record current and past meds (including OTCs and herbals) and psychosocial tx.
- Consider, w/ patient consent, obtaining an additional hx from family, significant other, or both.
- Perform mental status exam.
- If diagnostic uncertainty, consider validated structured clinical interviews for PTSD (i.e., Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), PTSD Symptom Scale – Interview Version for DSM-5 (PSSI-5)).
If pt at imminent risk of danger to self or others or medically unstable:
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Acute stress rxn/combat and operational stress rxn Consider initiating acute interventions as indicated. - Education and normalization, acute sx mgmt, social support
- Suggest: Brief CBT
Acute stress rxn - In most cases, sx will resolve rapidly w/ simple measures—e.g., reassurance, rest, ensuring safety.
- To prevent PTSD, there’s insufficient evidence to recommend for or against any pharmacotherapy.
- When ASR sx create social or occupational impairment for >72h, an ASD dx is often warranted, along w/ evidence-based interventions for this d/o.
Combat and operational stress rxn - Interventions emphasize proximity, immediacy, expectancy, simplicity.
- Promptly restore basic physiology (sleep, nutrition, hydration) while maintaining individuals w/in their units whenever possible, leveraging peer and command support systems, and remind the pt and unit leadership that COSRs are common and typically resolve promptly w/ basic supportive interventions.
- Those who don’t respond to initial supportive tx might warrant referral or evacuation, esp. if ongoing or worsening threats to safety.
- If sx >3 days, w/ persistent limitations, evaluate for ASD or other psychological disorders.
Acute interventions - To prevent PTSD: Initiate individual, manualized, trauma-focused, brief CBT. Insufficient evidence to recommend for or against any pharmacotherapy.
- Consider collaborative care or wellness-oriented activities.
Use shared decision-making to develop tx plan. - Summarize pt’s problems.
- Educate pt and family about PTSD.
- Discuss tx options, available resources, pt preferences.
- Arrive at shared decision on goals, expectations, tx plan.
Individual psychotherapies recommended over pharmacologic interventions. Initiate recommended individual, manualized, trauma-focused psychotherapy according to pt preference. If individual psychotherapy and recommended pharmacotherapy not feasible or preferred, offer suggested individual, manualized psychotherapy or Mindfulness-Based Stress Reduction. If none of the above options is feasible or preferred, consider other psychotherapies, other pharmacotherapy, or CIH or alternative approaches, based on availability, pt preference, and review of current evidence. - Psychotherapies
◦ Individual therapies – insufficient evidence for or against: Accelerated Resolution Tx (ART), Adaptive Disclosure (AD), Acceptance and Commitment Tx (ACT), Brief Eclectic Psychotherapy (BEP), Dialectical Behavior Tx (DBT), Emotional Freedom Techniques (EFT), Impact on Killing (IoK), Interpersonal Psychotherapy (IPT), Narrative Exposure Tx (NET), Prolonged Exposure in Primary Care (PE-PC), psychodynamic tx, psychoeducation, Reconsolidation of Traumatic Memories (RTM), Seeking Safety (SS), Stress Inoculation Training (SIT), Skills Training in Affective and Interpersonal Regulation (STAIR), Skills Training in Affective and Interpersonal Regulation in Primary Care (STAIR-PC), supportive counseling, Thought Field Tx (TFT), Trauma-Informed Guilt Reduction (TRiGR), Trauma Mgmt Tx.
◦ Components of manualized psychotherapy protocols: Insufficient evidence to recommend using them over, or in addition to, the full tx protocol for PTSD.
◦ Group tx: Insufficient evidence to recommend for or against any specific manualized group tx or to recommend use of group tx as adjunct.
◦ Couples therapies: Insufficient evidence to recommend for or against Behavioral Family Tx, Structured Approach Tx, or Cognitive Behavioral Conjoint Tx. - Pharmacotherapy
◦ Rx drugs – insufficient evidence for or against: amitriptyline, bupropion, buspirone, citalopram, desvenlafaxine, duloxetine, escitalopram, eszopiclone, fluoxetine, imipramine, mirtazapine, lamotrigine, nefazodone, olanzapine, phenelzine, pregabalin, quetiapine, rivastigmine, topiramate; suggest against: divalproex, guanfacine, ketamine, prazosin, risperidone, tiagabine, vortioxetine; recommend against: benzodiazepines.
◦ Psychedelics – insufficient evidence: psilocybin, ayahuasca, DMT, ibogaine, LSD.
◦ Cannabis, cannabis derivatives: recommend against. - CIH and alternative approaches
◦ Mind-body interventions – insufficient evidence: acupuncture, Cognitively Based Compassion Training Veteran version, creative arts therapies (e.g., music, art, dance), guided imagery, hypnosis or self-hypnosis, Loving Kindness Meditation, Mantram Repetition Program (MRP), Mindfulness-Based Cognitive Tx (MBCT), other mindfulness trainings (e.g., integrative exercise, Mindfulness-Based Exposure Tx, brief mindfulness training), relaxation training, somatic experiencing, tai chi or qigong, Transcendental Meditation®, yoga.
◦ Other interventions – insufficient evidence: recreational tx, aerobic or nonaerobic exercise, animal-assisted tx (e.g., canine, equine), nature experiences (e.g., fishing, sailing). - Augmentation tx
◦ Insufficient evidence: combination or augmentation of psychotherapy or meds w/ any psychotherapy or medication; MDMA-assisted psychotherapy.
◦ Antipsychotics – suggest against: aripiprazole, asenapine, brexpiprazole, cariprazine, iloperidone, lumateperone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone. - Nonpharmacologic biological treatments
◦ Somatic therapies – insufficient evidence: capnometry-assisted respiratory tx, hyperbaric O2 tx, neurofeedback, NightWare©, repetitive transcranial magnetic stimulation, stellate ganglion block, transcranial direct current stimulation.
◦ Suggest against: ECT, vague nerve stimulation.
- Technology-based tx
◦ Recommended: secure video teleconferencing to deliver recommended or suggested individual psychotherapies that have been validated for use w/ video teleconferencing or when other options are unavailable.
◦ Insufficient evidence: mobile apps or other self-help–based interventions; facilitated internet-based CBT.
If none of the above options is acceptable to the pt, consider treating other disorders, issues, or both and re-evaluate for PTSD tx later. Identify and address additional tx and support needs. - Consider tx for comorbidities and other identified problems.
◦ Co-occurring substance use or other disorders should not preclude use of individual, manualized, trauma-focused psychotherapies.
◦ Nightmares assoc w/ PTSD: prazosin suggested; insufficient evidence: Imagery Rehearsal Tx, Exposure Relaxation and Rescripting Tx, Imaging Rescripting and Reprocessing Tx, NightWare©.
◦ See other relevant VA/DoD guidelines. - Consider sx-specific mgmt—e.g., sleep, pain.
- Facilitate social support.
- Address Whole Health by offering CIH, alternative approaches, health and wellbeing coaching, recreation tx, etc.
Assess/address suicide risk.
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On tx, awaiting reassessment
Reassess sx and function. - Monitor and f/u as indicated.
- If persistent (≥1mo) or worsening traumatic stress sx or high risk for developing PTSD, assess for PTSD.
After sufficient time has passed for a clinically meaningful response, reassess PTSD sx, diagnostic status, functional status, QOL, additional tx and support needs, and pt preferences. - Clinically meaningful response times
◦ Psychotherapies: Initial tx effects typically noticeable after 4-8 sessions over 8-12wk. Need adequate dosage to be fully effective; might have attenuated effect if delivered less than weekly.
◦ Pharmacotherapy: Trial should be 8-12wk. Give SSRI or SNRI at appropriate dosage for adequate time to allow for full therapeutic effects before moving to alternative or augmentative tx options. Initiate at recommended starting dose and titrate based on clinical response and tolerability. See Pharmacotherapy Dosing Table.
Assess/address suicide risk. Pt improving, in remission - End PTSD tx or taper based on clinician judgment and pt preference, normalize sx fluctuations, discuss self-monitoring for sx that warrant future attention, and provide resources for seeking care in the future.
- Before end of psychopharmacology, discuss risks and benefits of discontinuing meds, including possible side effects and sx return. Make tapering schedule based on pt preference; discuss length of time required and anticipated life events and stressors. Discuss plan for monitoring during and post taper, including steps needed to reinstate pharmacology.
- If pt wishes to continue pharmacotherapy, investigate, and discuss continuing meds w/ behavioral health or primary care.
- Refer pt for tx of other disorders or functional issues—e.g., relationship distress.
- If desired, facilitate referral to health and wellbeing programs as part of VA’s Whole Health approach to care.
Pt not in remission or not improving
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